APVRS 2016 - Bangkok, Thailand - DAY 2

APVRSSHOWDAILY December 8-10, 2016

Bangkok, Thailand

The Official Conference News of APVRS 2016

Highlights

4

Get the latest ‘tips and tricks” in managing

uveitis

7 10

Day

2

Ancient Thai Culture 10th APVRS Opening Ceremony

Offers a Taste of

Imaging and therapy of choroidal tumors have come a long way

Enjoy more updates in

retinal surgery

by John McMahon

B Published by:

Editorial Team Creative Content Director

Matt Young

Chief Editor

Gloria D. Gamat Project Manager

Ruchi Mahajan Ranga Writers

John McMahon Kaylen Moore Designer

Winson Chua Photographer

Dwayne Foong

Media MICE Pte. Ltd.

6001 Beach Road, #19-06 Golden Mile Tower, Singapore 199589 Tel: +65 8186 7677 Fax: +65 6298 6316 Email: enquiry@mediamice.com www.mediaMICE.com

angkok, a city famous for its exquisite food, exotic sites, and unique traditions welcomes the 10th annual congress of the Asia Pacific Vitreo-retina Society (APVRS 2016). This year’s congress held in conjunction with the 38th Annual Meeting of the Royal College of Ophthalmologists of Thailand (RCOPT) comes together at the Bangkok Convention Center from December 8 through 10. Marking a decade in existence, APVRS 2016 brings together over 200 invited regional and international speakers sourced from 20 countries addressing a range of current challenges and leading practices in the vitreoretina subspecialty.

The ceremony opened with a taste of ancient Thai culture featuring a traditional drumming group of four young men dressed in traditional costumes playing a partially syncopated rhythm while chanting. Shortly they were accompanied by four women in lavish pink and green Lacoon outfits who performed a slow, elegant dance in front of the giant digital screen emblazoned with the 10th annual APVRS congress logo.

APVRS Congress President, Dr. Paisan Ruamviboonsuk, opened the ceremony by welcoming everyone to the city of angels. He outlined the itinerary that will cover a broad

range of subjects in medical and surgical vitreoretinal pathology, including macular degeneration, diabetic eye disease, macular surgery, uveitis, oncology, and pediatric retinal disorders. He talked about the opportunities that modern Bangkok offers visitors and invited all participants to enjoy the city during one of the nicest weather of the year. He suggested visiting the royal palace, or taking a river cruise and then made a joke about how many had already left to do some sightseeing.

Cont. on Page 9 >>

PhotooftheDay Worawit, a product specialist with Filtech Enterprise, shows off...and also shows off the Optomed Smartscope PRO non-mydriatic digital fundus camera

1

Abbreviation of Eylea Product Information: Presentation; 1 ml. solution for intravitreal injection contains 40 mg aflibercept Indication: for treatment of neovascular (wet) age-related macular degeneration (wet AMD), macular edema secondary to central retinal vein occlusion (CRVO), diabetic macular edema (DME), macular edema secondary to branch retinal vein occlusion (BRVO), myopic choroidal neovascularization (myopic CNV). Dosage and method of administration: For Neovascular (wet) age-related macular degeneration (wet AMD), the recommended dose for Eylea is 2 mg (equivalent to 50 microliters) intravitreal injection. EYLEA treatment is initiated with one injection per month for three consecutive doses, followed by one injection every 2 months. For Macular edema secondary to central retinal vein occlusion (CRVO), the recommended dose for EYLEA is 2 mg. After the initial injection, treatment is given monthly until visual and anatomic outcomes are stable for three monthly assessments. For Diabetic macular edema (DME), the recommended dose for EYLEA is 2 mg administered by intravitreal injection monthly for the first 5 consecutive doses, followed by one injection every 2 months. Macular edema secondary to branch retinal vein occlusion (BRVO), the recommended dose for Eylea is 2 mg. After the initial injection, treatment is given monthly. For Myopic choroidal neovascularization (myopic CNV), the recommended dose for EYLEA is a single intravitreal injection of 2 mg. Additional doses should be administered only if visual and anatomic outcomes indicate that the disease persists. Contraindications: Ocular or periocular infection, Active severe intraocular inflammation, Known hypersensitivity to aflibercept or to any of the excipients. Special warnings and precautions for use; Intravitreal injections including those with EYLEA, have been associated with endophthalmitis, Increase in intraocular pressurehave been seen within 60 minutes of an intravitreal injection, Women of childbearing potential should use effective contraception during treatment. Adverse reactions: Very common (≥1/10 patients) Conjunctival hemorrhage, Eye pain Selected adverse reactions: Arterial thromboembolic events (ATEs) are adverse events potentially related to systemic VEGF inhibition. There is a theoretical risk of ATEs following intravitreal use of VEGF inhibitors. Immunogenicity-as with all therapeutic proteins, there is a potential for immunogenicity with EYLEA. Incompatibilities: EYLEA must not be mixed with other medicinal products

โปรดอานรายละเอียดเพิ่มเติมในเอกสารกำกับยา ใบอนุญาตโฆษณาเลขที่ ฆศ. 726/2559

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

Treatment Options in Pathologic Myopia

by Kaylen Moore

K

icking off the Medical and Surgical Management of Pathologic Myopia symposium , international experts discussed treatment options of pathologic myopia.

With a unique and diverse population, a Singaporean study shared by Dr. Gemmy Cheung, MBBS(Lond), FRCOphth(UK), Senior Consultant, Ocular Inflammation and Immunology Department, Singapore National Eye Centre, highlighted the ethnic differences in myopia indications.

Compared to Indian and Malay populations, Chinese patients display a higher occurrence of myopia. Globally, myopia impacts about 40% of both Chinese and Japanese patients, yet only 15% to 20% in those who are ethnically European.

Worldwide the prevalence of myopia is increasing across ethnicities, and more people are experiencing moderate and high levels of myopia when compared to studies from the 1960s. It is one of the leading causes of blindness and visual impairment globally.

Further research will need to be completed to determine the relationship between school myopia and pathologic myopia, to see if interventions at an early period will translate into reduction in pathologic myopia and related blindness.

In another presentation, Dr. Danny Ng, BSc(JHU), MBBS(HKU), MPH (HKU), FRCS(Edin), FCOphth (HK), FHKAM (Ophth), Assistant Professor, Department of Ophthalmology & Visual Sciences, The Chinese University of Hong Kong, discussed OCT use for subretinal hyperreflective material (SHRM). In his presented study, 58 eyes of 50 patients with pathologic myopia and SHRM, including: active myopic CNV, quiescent myopic CNV with scar, and submacular hemorrhage without CNV. The sensitivity of OCTA for detecting myopic CNV was 63.3% in quiescent eyes, which was lower than the 94.1% in eyes with active CNV. Additionally, OCTA can detect chorioretinal atrophy adjacent to CNV similarly to FA and ICGA. OCTA in the future may be useful as a first screening to non-invasively differentiate submacular hemorrhage from myopic CNV.

Dr. Kenneth Fong

Myopic CNV may occur at any degree of myopia, and even in eyes without any typical myopic degenerative fundus changes, noted Dr. Lihteh W, M.D., University of Costa Rica. Symptoms such as visual acuity decreases, scotoma, and metamorphopsia require multimodality for a strong diagnosis and OCT scan is not enough to determine if a patient is suffering from CNV. Laser photocoagulation treatment has been shown to lead to scar expansion and atrophy, without long-term visual acuity gains, and patients show a high rate of recurrence. In a prospective pilot study of intravitreal bevacizurnab for myopic CNV, 32 eyes we followed with mean follow-up time of 24 months. These patients showed significant improvement of BCVA (30-45 letters), and 47% of eyes received only the loading dose.

The efficacy shown between the two modalities discussed was quite consistent; and focus should be paid in the future to early treatment of RNZ as crucial to prevent irreversible retinal damage, and with earlier treatment less injections are required.

Dr. Kenneth Fong, MA MB BChir (Cambridge), FRCOphth (UK), FRANZCO (Aust), CCT (UK), AM (Mal), Sunway Medical Centre, Selangor, Malaysia, took the stage to present about dome shaped macula (DSM), its incidence, pathogenesis and diagnosis, and implications for treatment.

It is typically an “inward bulge inside the chorioretinal posterior concavity of the eye, in macula� and found in 20% of highly myopic patients (of 1,118), with foveal detachment occurring in 70% of eyes with symptomatic vision loss.

Surgical treatment of myopic foveoschisis in high myopia was presented by Dr. Ian Wong, MBBS(HKU), M.Med (Singapore), FCOphthHK, FHKAM (Oph), FRCS (Edinburgh), FRCOphth, S8 Eye Clinic, Queen Mary Hospital, Hong Kong, with a focus on the lack of elasticity of the internal limiting membrane (ILM).

Current treatment is mainly vitrectomy, ILM peeling and gas injection. However, postoperative records show that full thickness macular hole formation has occurred in 13% to 28% of cases, meaning potential harm to almost one-quarter of patients.

To avoid trauma to the retina, modified ILM peeling spares the fovea by centripetal lifting and careful trimming to leave behind a small, circular area (~500um) of the ILM over the fovea untouched. This modified technique is promising, even over the small case series performed so far, and is able to be done without additional equipment or consumables compared to current methods.

Dr. Akito Hirakata, M.D., Professor, Department of Ophthalmology, Faculty of Medicine, Kyorin University, Mitaka, Japan, concluded his presentation highlighting that scleral shortening and vitrectomy with induction of PVD and/or ILM peeling could be useful to treat myopic traction maculopathy to prevent macular hole (MH) development, and a secondary toric IOL implantation may be useful to reduce surgical induced astigmatism after scleral shortening.

Closing out the morning session, Dr. Tzyy-Chang Ho, M.D., attending physician and clinical associate, Department of Ophthalmology, National Taiwan University Hospital, Taiwan, presented a dye free, noninvasive method for foveal repairing ILM peeling surgery for myopic macular hole/retinal detachment. For repairs of macular hole (MH), or macular hole retinal detachment (MHRD) in highly myopic eyes, this C-shaped flap method significantly reduces the standard prone time for patients and does not interfere with any tissue deeper than ILM, with no intentional drainage of SRF performed.

3

4

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

The Cutting Edge

of Managing Uveitis vessels. From this, it is possible to create a measurement for vascular volume that was previously unknown. Dr. Pichi concurs with the need for multimodality, as OCTa does not have the dynamic capabilities of indocyanine green (ICG) angiography, but is excited to make the jump from subjective to objective measurement of uveitis.

by Kaylen Moore

C

urrent treatment of uveitis is moving forward, with use of ocular imaging and laboratory tests including optical coherence tomography (OCT), wide-field photo angiography, polymerase chain reaction (PCR), newly introduced drugs, and drug delivery systems to go further than traditional clinical examinations.

Dr. Ann-Marie Lobo, M.D., Assistant Professor of Ophthalmology and CoDirector, Uveitis Service, University of Illinois College of Medicine, Chicago, began the session by asking when it is appropriate to order tests. Do you need to rule out infectious processes? Is it an atypical presentation? Are you looking for tailored therapy due to drug resistance?

PCR testing can detect organisms which are difficult to grow in culture, organisms even with prior antimicrobial therapy, and organisms sequestered on surfaces of prosthetic materials in ocular fluid samples.

For viral retinitis (HSV/VZV/CMV), there is a high sensitivity (82%) and high specificity (97% to 100%) when using PCR in diagnosis of infectious posterior uveitis.

Also, Dr. Lobo emphasized the importance of immediate processing of samples, as delayed sample processing is a culprit for false positives.

Using multimodal imaging for uveitis was the topic for Dr. Hyeong Gon Yu of Seoul National University Hospital, South Korea, as he emphasized the growth of multimodal imaging in all areas of ophthalmology. He reminded the audience of how different imaging types can complement one another, and their combination of data can be even greater than the sum of their parts.

With uveitis, multimodal imaging allows for identifying the pathophysiology through multilayer involvement of the retina, retinal pigment epithelium (REPE) and choroid. Dr. Yu was also excited about the opportunities coming from ultra-widefield (UWF) imaging, with its allowance of 200-degree photographic view of the fundus, which is ideal for evaluating the peripheral retina at a glance.

Highlighting detailed intraoperative OCT in uveitis, Dr. Thanapong Somkijrungroj, Bumrungrad International Hospital, Thailand, noted that the Rescan 700 (Carl Zeiss Meditec, Jena, Germany) provides real time HD intraoperative OCT (iOCT), with the projection directly into the surgeon’s right eye. Though there were concerns over additional time this enhanced procedure would take, overall surgeons only spent 4.9 minutes longer, according to results of his study.

Reported in the DISCOVER study, 61% of surgeons believed that membrane peeling was complete prior to iOCT scan, yet of the iOCT scans, 22% actually revealed residual occult membranes that the surgeons decided needed additional peeling. iOCT functions for both anterior and posterior segment surgery, and can impact surgeon decision making for better outcomes.

These technologies can provide better diagnosis and monitoring for patients, with faster detection of recurrence and improvements.

Talking about masquerade syndrome in uveitis, Dr. Un Chul Park, M.D., New York Eye and Ear Infirmary of Mount Sinai, New York, USA, stressed the need for prompt and correct diagnosis. A 2004-2012 study shows that 2.5% of patients presenting with uveitis at the Nationa Eye Institute (NEI) were suffering from neoplastic masquerade syndrome. These patients are more likely to be male, older, nonAfrican American, suffering from unilateral posterior segment inflammation.

Further, Dr. Francesco Pichi, M.D., Cleveland Clinic, Cleveland, USA, focused his discussion on optical coherence tomography angiography (OCTa). With its ability to give information at the deep capillary layer, OCTa can create a 3-D rendering of the iris, with isolation of the

The audience was reminded that atypical features and resistance to conventional steroid therapy may require further analysis to reach the correct diagnosis, while saving the patient’s vision and life.

In addition, diagnostic vitrectomy can aide in identifying these copycat diseases.

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

Operate with Your Head Up

by Gloria D. Gamat

I

nstead of looking through the eyepiece of a microscope, the digitally assisted vitreoretina surgery (DAVS) platform allows ophthalmologists to see things from a surgical perspective better than ever before.

At its exhibition booth at the APVRS Congress 2016 in Bangkok, Thailand, Alcon welcomed delegates for a handson demonstration of the company’s new DAVS digital microscopy platform – the NGENUITY 3D Visualization System.

The MUST Trial (Steroid Implants and Uveitis) was presented by Professor Lyndell Lim, MBBS, FRANZCO, Senior Associate Ophthalmologist, Eye Surgery Associates, Melbourne, Australia, with a focus on steroid implants among all treatments of uveitis. The Multicenter Uveitis Steroid Treatment (MUST) Trial followed 255 patients (479 eyes) and was randomised 1:1 between Retisert steroid implants (Bausch & Lomb, Rochester, New York, USA) and standard systemic immunosuppression. All participants were presenting uveitis currently, or recently active (within 60 days).

Unsurprisingly, patients with poor vision at the baseline had the most visual gains.

The Retisert group lead in visual gains initially, but the systemic group began to catch up. At 24 months, both groups showed various side effects.

After 5 years, virtually 100% of patients needed cataract surgery and the pellets have fallen off. However, inflammation was under better control in the implant group when compared to the systemic group for uveitis relief.

Closing the session, Dr. Yu Cheol Kim, M.D., Keimyung University, South Korea, discussed posterior uveitis and highlighted that less invasive pars plana vitrectomy (PPV) makes a difference.

Vitrectomy can be an indispensible tool for uveitis, icro-incision vitrectomy surgery (MIVS) and wide viewing systems are preferred for high outcomes. For best outcomes, Dr. Kim emphasized the role of patient selection, preoperative and postoperative inflammation control.

The NGENUITY 3D Visualization System integrates a 3D camera, which is attached to the operating microscope optics, and a flat panel, high-definition 4K OLED monitor. Here, the surgeon can view a 3D, stereoscopic image of the surgical field through passive glasses. The bottom line is that this provides higher magnification, enhanced depth of field, enhanced peripheral acuity and improved peripheral awareness. From now on, you can think of using a standard surgical microscope like riding a bicycle and looking at the tire: While you can see what’s going on, you are more likely to crash the bike. In using the NGENUITY 3D Visualization System, you can look up and be far more aware of the surgical surroundings.

“The system is excellent and very interesting,” said Dr. Ik Soo Byon of South Korea. “It has a very good resolution and finer 3D visualization that would enable surgeons to operate well and potentially may lead to better patient outcomes.”

The ergonomics in this heads-up technique often delivers the initial ‘wow’ factor to most surgeons.

“The system is very amazing,” shared Dr. Zhuping Xu, APVRS 2016 delegate from China after trying the machine herself.

“Ergonomically, it is better for the surgeons both in clinical practice and for teaching purposes. Patient outcomes using this system would be a lot better.”

Also, the electronic amplification of the camera’s signal results in increased image brightness, allowing use of reduced endoillumination levels.

“

[The system] has a very good resolution and finer 3D visualization that would enable surgeons to operate well and potentially may lead to better patient outcomes.

- Dr. Ik Soo Byon

”

“

Ergonomically, it is better for the surgeons both in clinical practice and for teaching purposes.

”

- Dr. Zhuping Xu

The machine can “provide clearer visual field on the screen compared to looking through the microscope.

- Dr. Yue Qiu

”

“The machine can provide clearer visual field on the screen compared to looking through the microscope,” said Dr. Yue Qiu, a young ophthalmic surgeon from China.

“The 3D is very good, providing an indepth view of the eye.”

Dr. Qui highlighted that the system is very convenient because it can be paired and is compatible with other brands of microscope and OCT. “More importantly, a low degree of light can be used while operating,” she concluded. “This is good for the patient’s macula and will provide less strain to the eye of the doctor doing the operation.”

5

6

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand Spotlight on Key Symposium

Intravitreal Sirolimus A

ny part of the eye can be affected by uveitis, which can be infectious or noninfectious. In non-infectious uveitis (NIU), the pathophysiology is often of autoimmune origin, manifesting secondary to systemic diseases or due to local conditions.

Inflammation of the uvea and adjacent structures in NIU is mediated by T cells and perpetuated by proinflammatory cytokines.

Therefore, treatments for NIU target the inflammatory pathology. This includes systemic and local corticosteroids, systemic immunosuppressants and biologics.

Although systemic corticosteroids are effective in a majority of patients, its longterm use is associated with a risk of serious adverse effects.

New therapy on the horizon…

What if NIU can be treated by a localized immunoregulator? In that case, serious adverse effects associated with the use of systemic immunosuppressants would not be an issue.

Enter intravitreal sirolimus – a local immunoregulatory therapy for managing non-infectious uveitis of the posterior segment (NIU-PS). This novel agent is an mTOR inhibitor that plays immunoregulatory role by interrupting T-cell proliferation driven by interleukin-2 (IL-2) and other proinflammatory cytokines, with minimal systemic exposure.

Promising Novel Localized Immunoregulatory Therapy for Non-Infectious Uveitis of the Posterior Segment

SAKURA Study 1 is the first of two Phase III, randomized, double-masked, multinational studies conducted in the European Union, India, Israel, Japan, Latin America, and the United States, evaluating the long-term safety and efficacy of intravitreal sirolimus. The study’s primary objective is to evaluate the safety and efficacy of the intravitreal injection of 440 μg and 880 μg sirolimus versus 44 μg for the treatment of active NIU-PS. As part of the SAKURA Study 1, Dr. Alay S. Banker, M.D., from Banker’s Retina Clinic and Laser Centre, Ahmedabad, India, and his team examined the 12-month safety outcomes of intravitreal sirolimus in Indian subjects with active NIU-PS. Study findings demonstrated that overall, a significantly higher proportion of Indian subjects receiving the 440 μg dose (31.4%) of intravitreal sirolimus injections for NIU-PS achieved a resolution of inflammation (VH of 0) when compared to those who received the active control dose of 44 μg (10%).

The investigators highlighted that although ocular adverse events (AEs) and serious AEs observed with intravitreal injections of sirolimus in SAKURA Study 1 were not unexpected, the incidence rate of ocular serious AEs did not increase with long-term use.

“The 440 μg intravitreal sirolimus injections may be an efficacious and safe therapeutic option for non-infectious uveitis of the posterior segment,” shared Dr. Banker. “Also, the SAKURA Study 2 may provide additional data on the

Details of the SAKURA Study 1 findings will be presented at the APVRS Congress 2016 on December 10, 2016 (Saturday), 14:30 – 16:00 hrs, at Lotus 11.

The findings are based on research by the following physicians (and please note their presentation titles as well):

Dr. Alay S. Banker

Dr. Vishali Gupta

Intravitreal Sirolimus: Long-Term Safety Results in Indian Subjects with Noninfectious Uveitis of the Posterior Segment

24-Month Safety Outcomes: Treatment of Noninfectious Uveitis of the Posterior Segment with Intravitreal Sirolimus

For more information, please contact: Dr Femmy Yunia Bahroen at femmy.bahroen@santen.asia This symposium preview has been supported by an educational grant from Santen.

References: Mudumba S, Bezwada P, Takanaga H, et al. Tolerability and pharmacokinetics of intravitreal sirolimus. J Ocul Pharmacol Ther. 2012;28(5):507-514.

Nguyen QD, Merrill PT, Clark WL, Banker AS, et al.; Sirolimus study Assessing double-masKed Uveitis tReAtment (SAKURA) Study Group. Intravitreal Sirolimus for Noninfectious Uveitis: A Phase III Sirolimus Study Assessing DoublemasKed Uveitis TReAtment (SAKURA). Ophthalmology. 2016;123(11):2413-2423.

benefit/risk profile of intravitreal sirolimus for the treatment of NIU-PS,” he added.

In a similar study, Dr. Vishali Gupta, M.D., from Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India, and her team evaluated the 24-month safety outcomes of intravitreal sirolimus for the treatment of active NIU-PS. The investigators found that the most efficacious dose of 440µg was observed to be safe and tolerable over the 24-month study period. More importantly, the systemic exposure to sirolimus fell below the immunoregulation threshold and no clinically relevant systemic safety issues were reported in subject patients.

“A major issue in NIU is that it keeps coming back. To prevent recurrences, a form of immunoregulator therapy needs to be administered,” said Dr. Gupta.

“But the problem with treatment is that it comes with a lot of systemic side effects. In NIU-PS, the disease is local in the eye, and a local immunoregulator is the ideal treatment scenario,” she explained.

“Uveitis is a potentially blinding disease, and we don’t have a better alternative to systemic immunoregulator at the moment. Intravitreal sirolimus will allow treatment of the condition in a localized manner (without the systemic side effects) and I’m so looking forward to it,” she concluded.

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

Choroidal Tumors:

Improvements in Imaging and Therapy different types of uveal metastasis and similar lesions were presented to highlight diagnostic issues often encountered by doctors.

by John McMahon

T

he APVRS 2016 session on improvement in imaging and therapy of choroidal tumors began with a brief history of common choroidal tumors, which was presented by Dr. Santosh Honavar, MD (AIIMS), FACS, Director of Medical Services, Centers for Sight, Hyderabad India, in which he summarized the progress in diagnostic technique and treatment of uveal melanoma. Dr. Honavar showed slides illustrating the commonalities of occurrence in certain populations before beginning the discussion of racial differences in tumor rates – that would continue as a theme for most speakers. They pointed out however, that the occurrence among Caucasian patients far outweighs that of Asians.

The second speaker, Dr. Evangelos Gragoudas, M.D., Director, Retina Service, Massachussets Eye & Ear, Harvard Medical School, presented a 40-year history of the use of proton beam irradiation as treatment for uveal melanoma. Dr. Gragoudas highlighted that before proton beam irradiation, the standard for treating uveal melanoma was removal of the eye (enucleation). Following the discussion was a brief description of the development of proton beam therapy, it’s side effects and benefits. He looked to a multidisciplinary approach in the future of pairing with a combination of radiation and antiangiogenic agents to decrease the amount of cytotoxic effects of radiation on normal tissue.

Furthermore, Dr. Hiroshi Goto, M.D., Department of Ophthalmology, Tokyo

Medical University, Japan, delivered the efficacy of specific scintigraphy for the diagnosis of uveal melonoma. He discussed a study of 99 patients where single-photon emission computed tomography (SPECT) images were obtained after the intravenous injection of N-isopropyl iodoamphetamine. The study concluded that intravenous injection of N-isopropyl iodoamphetamine is useful for the diagnosis of malignant uveal melanoma as well as a measured step against misdiagnosis.

Talking about choroidal melanoma, Dr. An-Ning Chao returned to the topic of the racial difference in rates of developing choroidal melanoma. Dr. Chao emphasized that choroidal melanoma is the most primary intraocular malignancy in adults and discussed the usefulness of the American Joint Committee on Cancers Classification of Tumors in staging the condition (i.e. categories T1-T4). Dr. Chao concluded her presentation with slides illustrating the size categories of tumors, differential diagnosis of pigmentation and the clinical features of choroidal melanoma.

On the other hand, Dr. Duangnate Rojanaporn’s lecture on lesions that can simulate choroidal melanoma focused on the issue of diagnostic difficulties.

Using the mnemonic device, “to find small ocular melanoma, using helpful hints daily”, recognizes thickness, fluid, size, orange pigment, ultrasound, halo and density as the key indicators to differentiate between lesions and melanoma. Slides and video examples of

The role of genetic testing for uveal melanoma was presented by Dr. Minoru Futura, M.D., Fukushima Medical University, Japan. The breakdown of the prognostic risk factors, as highlighted

by Dr. Futura, includes basal diameter, macular thickness, extrascleral extension, epitheloid histology and mitotic rate. Dr. Futura went on to discuss a small study involving only 6 patients in Fukushima, Japan, as being inconclusive. “Genetic testing has come of age because of its ability to predict the likelihood of developing uveal melanoma and perhaps more importantly for the peace of mind of patients,” he said.

Finally, Dr. Jerry Shields, M.D., a distinguished ocular oncology expert at Wills Eye Hospital, Philadelphia, ran through a brief history of uveal melanoma’s diagnostic and treatment changes. Starting with radioactive injections from the 1970’s to current practices, including a thorough discussion of simply observing the growth of tumors.

Additionally, Dr. Carol Shields, M.D., from the Wills Eye Hospital, discussed the scenario of the future of melanoma management by presenting the newest practices of light therapy, targeted drugs, vascularization blockade, and then continued to describe T-cell training.

Dr. Shields ended the session with an anecdote about former U.S. President Jimmy Carter receiving T-cell training treatment with the result of complete remission from brain cancer.

7

8

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

Managing Complications of Anterior Segment Surgery With on-going technical trouble and the power presentation coming in and out, Dr. Doric Wong, Singapore National Eye Centre, presented on ‘Anterior Segment Surgery in the Presence of Retinal Pathology’ focused on diabetic retinopathy’s ICO guidelines for diabetic eye care. This led to the pro’s and con’s of surgery and drug treatment. He concluded with the connection between age related macular degeneration and its relation to cataract surgery.

by John McMahon

T

he session on managing complications of anterior segment surgery featured experts who shared their techniques to address issues such as posterior capsular rupture and vitreous loss, intraocular lens dislocation and management, iris trauma and repair options, complications of glaucoma surgery and its management, intraocular surgery in the context of preexisting retinal pathologies, current management of postoperative endophthalmitis, and advanced corneal vitreoretinal surgery in the context of corneal opacities.

Dr. Pakitti Tayanithi, M.D., associate professor, Bumrungrad International Hospital, Bangkok Thailand, started off with ‘Complicated Cataract Surgery— Tips and Tricks in Managing Posterior Capsule Rupture’ by listing the three key factors for preparing for capsular rupture: recognize, stop, stabilize it. While a good surgeon can avoid a rupture more than 90% of the time, one should always be prepared, emphasized Dr. Tayanithi, and concluded his presentation with a series of precautions to avoid grasping vitreous.

Dr. Sze Guan Ong, M.D., founding partner and senior consultant ophthalmic surgeon at Eye & Retina Surgeons, Camden Medical Centre, Singapore, discussed the complicated topic of ‘Cataract Surgery— Current Evidence and Management of Dislocation/ Subluxation of Lens and intraocular lens (IOL)’. It was a point by

point break down of lens removal, IOL dislocation followed by options and choices of IOL techniques. Comparing scleral suture with sutureless procedures and weighed the disadvantages and benefits of each.

On the other hand, Dr. Tjahjono Gondhowiardjo, Jakarta Eye Center, Indonesia, began his presentation with serious technical difficulties, but once the problems were straightened out he discussed ‘Iris Trauma/Iris Loss—Suture Techniques and Artificial Iris Options and touched on the subjects of iris suturing, iridodialysis reconstruction and showed a video featuring different iridia devices. He closed with a comparison of artificial iridia versus sceleral IOL. Dr. Boonsong Wanichwecharungruang, M.D., Bumrungrad International Hospital, Bangkok Thailand, came to the podium next with ‘Posterior Segment Complications of Glaucoma Surgery and Cyclodialysis’. He started with a comparison of treatments, specifically, drug therapy or surgery, noting that 50% of glaucoma is very successfully managed with drugs. Where surgery is necessary it is limited by poor success in the control of intraocular pressure and serious complications. He finished the discussion with a video of a 27 year old male patient suffering from angle closure glaucoma that was successfully treated with laser periphery iridotomy (LPI).

Presenting ‘Management of Postoperative Endophthalmitis, Dr. I-van Ho, Retina Associates, Sydney, Australia, began with the primary measure to determine the outcome of postoperative visual acuity. Secondary outcomes include complications requiring secondary endophthalmitic surgery. He ended his truncated talk by predicting further standard evaluation of drug management to decrease postoperative side effects.

Kazuhito Yoneda , Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan, made an enlightening fast breakdown of his lecture on ‘Surgery in the Context of Corneal Opacities’. He quickly scanned videos of different techniques outlining corneal topography and confocal scanning. With almost no time left in the session, Dr. Martin Brelan, M.D., The Cleveland Clinic, Ohio, USA, summarized his discussion on ‘Intrascleral Haptic Fixation for Secondary IOL Implantation’ using a series of detailed videos. He quickly demonstrated several methods of placing sceral IOLs, concluding with his preferred pull method and demonstrating that as the session broke up.

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand >> Cont. from Page 1

Prof. Dennis Lam

Professor Andrew Chang, APVRS 2016 Congress Scientific Program Committee Chairman praised the international contributors who made up this year’s organizing committee. He spoke about the range of sub-topics and the depth of knowledge brought by this year’s speakers on such a wide range of current practices to address future challenges.

He wished all attendees a fruitful and relaxing visit and hoped to see each at the second night’s Sea World dinner extravaganza.

Dr. Taraprasad Das, APVRS President, welcomed the attendees with a brief description of the rich history and culture of Bangkok before going on to discuss the many events offered this year at the congress. He spoke of the history of the APVRS, how it has grown from just a few doctors to the current 1,800 members.

He spoke further on the changes and development that he has seen in his career in treatment and diagnosis of eye disease, and particularly of the conditions that are prevalent in the region.

Further, APVRS Secretary General Prof. Dennis Lam congratulated the congress organizers for attracting such a distinguished panel from around the world and declared that this year’s meeting is all about breaking barriers, building bridges and making new friends.

He spoke of the challenges of putting together the vitreoretinal congress due to political un-rest in the nation and asked for a round of applause for Dr. Paisan Ruamviboonsuk for his tenacity in making the 2016 event possible. He continued

Dr. Taraprasad Das

Dr. Paisan Ruamviboonsuk

to speak on the developing importance of Southeast Asian countries for their rapid growth in the industry matching the rapid needs of patients. “APVRS has developed from scratch to strength and is looking forward to much further growth by offering fellowships in education, and expanding care throughout the region,” Prof. Lam concluded.

and dean of Peking University Eye Center.

Also, she is an honorable president of the Chinese Ophthalmology Society and past president of both the Chinese Ocular Fundus Diseases Society and the APVRS. Prof. Li spoke briefly giving thanks to her mentor and colleagues and then abstracted her award winning lecture to an appreciative audience.

Yesterday’s opening ceremony was closely followed by the presentation of the APVRS Tano lecture award to this year’s recipient, Prof. Xiaoxin Li, professor at the Eye Institute of Peking University People’s Hospital and the president of Xia Men Eye Center. She is an academic committee member of Peking University Health Science Center

Closing the ceremony, Dr. Paisan Ruamviboonsuk took the stage once again with gratitude to all and a hope that the APVRS continues to reach new heights. “The Congress has become more and more international, enabling ophthalmologists from around the world to meet and network,” he concluded.

Prof. Xiaoxin Li and Dr. Taraprasad Das

9

10

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

Latest Advances in Retinal Surgery the camera view and it is possible to add in real-time data, all controlled with head and eye trackers.

The device’s “shutters” can be opened or closed, to give the surgeon the option of viewing as much or little as needed.

by Kaylen Moore

T

he newest developments in retinal surgery were presented by an international faculty of respected retina surgeons, including new visualization techniques and methods for addressing challenging conditions.

For example, how do you manage floaters for patients with persistent symptoms?

Without proper care, they can lead to visual impairment, migraines and anxiety.

Currently they are treated by YAG laser vitreolysis, vitrectomy for vitreous floaters (FOV), or deep anterior vitrectomy.

Opening the session, Dr. Dennis Lam, M.D., Sun Yat-sen University, Guangzhou, China, shared a new treatment method, using Alcon’s Infiniti machine. The procedure is a two-part surgical option, emphasized Dr. Lam. Firstly is anterior vitrectomy without going beyond the temporary margin. Once this is complete (usually 1-2 minutes) the patient is asked to confirm the removal of floaters in the line of vision. The surgeon will then proceed with the removal of the elastic in the anterior chamber, and the entire procedure is finished in about 10 minutes.

After operating on 100 eyes, 80% of patients said that they are very satisfied, and there have been 0 cases of retinal detachment.

Sharing his findings in endovascular surgery for retinal vein occlusion (RVO), Dr. Kazuaki Kadonosono, M.D., professor of ophthalmology, Yokohama City University Graduate School of Medicine, Japan, discussed that in 89 eyes undergoing the

operation, 73 eyes had improved visual acuity at 6 months, though there was a relatively high rate of recurrence of macular edema (23%). Furthermore, Dr. Kadonosono highlighted cannulation, and how advanced surgical procedures can benefit from advanced technology – which allows surgeons to fix their arms and reduce tremors, while digital microscopes allow performance of delicate procedures more precisely.

On the other hand, Dr. Fernando Arevalo, M.D., FACS, The Wilmer Eye InstituteJohns Hopkins University School of Medicine, Baltimore, Maryland, USA, shared his findings in optic disc pit (ODP) maculopathy, ending with a lack of recommendation for JLP, internal limiting membrane (ILM) peeling, and gas injections. Although he did suggest a long period of observation for ODP maculopathy (12 months) before a secondary intervention as most patients will improve over that period.

With some novel technology, Dr. Anat Loewenstein, M.D., professor of ophthalmology, Sackler Faculty Tel Aviv, Israel, got the audience excited about augmented reality (AR) video microscope for retina surgery as a replacement of operating microscopes. Based on a fighter pilot’s helmet and visual screen, this new technology uses a head and eye tracker for seamless controls. The two ultra-resolution cameras replace the tradition microscope and project to a head wearable display (HWD) worn by the surgeon. The display can show both

Following was Dr. Kenneth Fong, MA MB BChir (Cambridge), FRCOphth (UK), FRANZCO (Aust), CCT (UK), AM (Mal), Sunway Medical Centre, Selangor, Malaysia, with an in-depth discussion of the use of dye use during surgery (chromovitrectomy), and the importance of excellent contrast, low toxicity, and high biocompatibility. He concluded by recommending brilliant blue G (BBG) due to its variety of benefits.

Then Dr. Maria Berrocal, ophthalmologist from San Juan, Puerto Rico, took center stage with scleral buckling surgery with chandelier illumination. This technique, noted Dr. Berrocal, while effective, most surgeons are not trained to complete it successfully; and many do not like to perform the procedure due to poor visibility. This leads to complications like inadequate buckle placement, missed breaks, retinal incarceration, among others. But with light sources, the optimized visualization can be a great teaching scenario. A microscope buckle with chandelier illumination and illuminated laser takes advantage of optimal visualization and magnification, with the retina fully attached on the table, and possibilities for assistant viewing.

With an impressive decrease in recovery time, Dr. Chi-Chun Lai, M.D., professor and chairman of ophthalmology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan, closed out Thursday’s session with his method for macular hole retinal detachment (MHRD). With an inverted ILM clump reposition and auto-blood clot, he was able to reduce the patient prone time from two weeks down to one day. His patients have experienced 96% success of retina reattachment, and his tested collagen type 4 also improved healing of the macular hole.

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

Pictures From Around the

Ophthalmic Conference World

East Vs. West match at ASCRS New Orleans

Bejeweled burger at AAO Chicago

Allergan booth looking homey at ESCRS Copenhagen

Dancers at APAO Taipei

Posterior segment PowerPoint at an AOS Bangkok retina forum

Making clinical points on a motorbike at AAO Las Vegas

Augmented Reality demos at Abbott booth, APACRS Bali

Getting local at a Malaysia-Singapore meeting in Kuching

Ancient eye anatomy at RANZCO Melbourne

Local talent at APVRS Sydney

Smiling at Alcon symposium at RANZCO Wellington

11

See The Future, Right Now.

YOU’ VE NEVER SEEN YOUR PROCEDURES QUITE LIKE THIS.

Featuring next-generation visualization technologies and an intelligent ocular-free design, the NGENUITY® 3D Visualization System establishes a powerful platform for Digitally Assisted Vitreoretinal Surgery (DAVS).